北美精算师真题大纲讲解November2001Course8M（三），大家用心记在脑子里呀，内容很多，但别怕看不完。
　　14. (11 points) It is currently late in the year 2000. As The Bedford Group’s pricing actuary,
　　you must prepare manual rates for 2001. In addition to data from Table MC – 6, you
　　have decided to use the following assumptions:
　　? Calendar year 2000 will be used as the experience period
　　? Anticipated increase in average charge per service from 2000 to 2001
　　Hospital Services = 10%
　　Physician Services = 5%
　　All Other Services = 15%
　　? Administrative Costs will increase by 4%
　　? Adjustments for risk sharing, bonus, and withhold arrangements will not
　　affect the currently reported results
　　? Average charges per service are the same for the HMO and POS products
　　? Utilization changes occur uniformly for both the HMO and POS
　　(a) Using the information provided:
　　(i) (3 points) Calculate the expected PMPM hospital inpatient costs for the
　　HMO and POS plans separately for 2001. Show your work.
　　(ii) (1 point) Determine the required total premium PMPM assuming the total
　　projected claims costs for 2001 are $170.00 and $185.00 PMPM for the
　　HMO and POS products respectively. Show your work.
　　(b) (4 points) The head of the Marketing Department has to present a quote effective
　　January 1, 2001 for the HMO product to a prospect, Bailey Industries. He has
　　indicated three-tier premium rates are required.
　　Current Rate Information for Bailey Industries
　　Tier Number of
　　Contracts
　　No. of Persons
　　per Contract
　　HMO Ratio to
　　Single
　　POS Ratio to
　　Single
　　Single 35% 1.0 1.0 1.0
　　Two Party 15% 2.0 1.9 1.7
　　Family 50% 3.8 3.5 4.2
　　COURSE 8: November 2001 -11- GO ON TO NEXT PAGE
　　Managed Care
　　Afternoon Session
　　14. Continued
　　(i) Calculate the manual premium rates by tier for Bailey Industries using HMO
　　rate relativities in the table above and the total premium you calculated in
　　(a) (ii) above. Show your work.
　　(ii) Bailey Industries requires that the HMO premium rates be recalculated
　　using the POS rating relativities. Develop revised rates to meet this
　　requirement. Explain why offering HMO premium rates that mirror the
　　POS rating slope may or may not be in Bailey Industries’ best interest.
　　Show your work.
　　(iii) Describe the documentation you would include in your files to demonstrate
　　that Actuarial Standards of Practice concerning HMOs or other managed
　　care health plans were followed in your work.
　　(c) (3 points) Outline a report for Bailey Industries explaining the potential impact of
　　adverse selection resulting from the following types of market reform:
　　(i) Insurer Rules of Issue,
　　(ii) Government mandated benefits and laws,
　　(iii) Rating methodologies, and
　　(iv) Marketing practices.
　　COURSE 8: November 2001 -12- GO ON TO NEXT PAGE
　　Managed Care
　　Afternoon Session
　　Questions 14 through 16 pertain to the Case Study
　　15. (14 points) You are an actuary for The Bedford Group. A meeting has been called to
　　address spiraling costs in two areas: behavioral health/chemical dependency and
　　radiology services.
　　Radiological Services
　　Your CEO also has concerns regarding the increase in radiology costs even though
　　utilization has decreased. The VP of Provider Contracts is predicting a 25% increase in
　　2001 in physician radiology average charges. None of the benefit plans sold require any
　　member cost sharing for physician radiology benefits.
　　Behavioral Health and Chemical Dependency (BH/CD)
　　Your CEO is considering carving-out all BH/CD services due to increasing costs and
　　increased regulatory pressures. Total claims for BH/CD services in 2000 were $24
　　million for both HMO and POS products.
　　Lighthouse Behavioral Services (LBS), a managed behavioral health company, has
　　approached The Bedford Group to provide the full continuum of care for BH/CD
　　services. LBS will provide all BH/CD services on a capitated basis. After reviewing The
　　Bedford Group’s 2000 BH/CD claims, LBS believes they can affect BH/CD claim costs
　　under the following assumptions:
　　? LBS uses The Bedford Group provider contracts
　　? Utilization of services in Hospital ID1 will not change
　　? Utilization of services at Hospital ID2 and ID3 will be reduced by 50%
　　? 80% of the reduced Hospital ID3 services will then be moved to Hospital ID2
　　? Outpatient utilization will increase by 15%
　　? Hospital ID1 and ID3 costs/admission will not change
　　? Hospital ID2 costs/admission will increase by 50%
　　? Outpatient charges/services will go down by 25%
　　? LBS will add an administrative charge of $1.10 PMPM
　　(a) (2 points) Discuss differences between BH/CD and radiology services in how
　　access to care is obtained and utilization is controlled in a managed care
　　environment.
　　(b) (2 points) Describe mechanisms The Bedford Group can use to reduce provider
　　reimbursement costs for BH/CD and for radiology services.
　　COURSE 8: November 2001 -13- GO ON TO NEXT PAGE
　　Managed Care
　　Afternoon Session
　　爱是苛求的，因为苛求而短暂。友谊是宽容的，因为宽容而长久。——高顿网校做人道理

 

 
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